case report of ptosis patient

1. Case Report
By Sameep Adhikari
August 30,
2015
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2. Case History
Name- xxxx
Age/sex- 41 yrs/ F
Occupation- Housewife
Complaints-
RE- c/o unilateral drooping of upper eyelid
that varies during the day and aggravated after use
of Botulinum toxin injection x 4 months
LE- No c/o drooping of eyelid
BE- c/o gradual decrease in distance vision x
2 months
RE- No other specific ocular complaints
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3. Previous ocular history-
No h/o glasses wear
No h/o surgery and trauma
General health-
No h/o DM and HTN
h/o botulinum toxin injection used for cosmetic
purpose
Family history-
Not contributory
Recent investigation-
Nil
Current treatment-
Nil
Allergy-
Not aware of any
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4. Ocular examination
 Visual Acuity-
Distance visual acuity with snellen chart (U/A)
RE- 6/9 PH 6/6p (upper eyelid uplifted)
LE- 6/9 PH 6/6
Near visual acuity with continuous text chart @
38 cms
RE- N6
LE- N6
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5.  Refraction-
 Objective refraction
RE- +0.25 DS/ -1.00 DC x 100
LE- ±/ -0.50 DC x 90
 Subjective refraction
RE- ±/ -0.75 DC x 100 (6/6)
LE- ±/ -0.50DC x 80 (6/6)
 Duochrome-
RE- Balanced
LE- Balanced
 JCC-
BE- JCC refined
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6.  Keratometer
RE- 45.00D@V [7.5mm]
44.00D@H[7.67mm]
LE- 45.5D@V[7.41mm]
45.00D@H[7.5mm]
 Extra ocular motility-
0 0 0 0 0 0
0 0 0 0
0 0 0 0
0 0
RE- SAFE LE- SAFE
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7.  Hirschberg test-
ortho
 Pupils-
RE- PERRLA
LE- PERRLA
No RAPD
 Colour vision with Ishihara plates @75 cms
RE- 25/25 (correct response)
LE- 25/25 (correct response)
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8.  Confrontation-
RE-
within normal limits
LE-
within normal limits
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9. Ptosis evaluation
 Head posture
Normal
 Palpebral fissure height
RE- 7.5 mm
LE- 11 mm
 Marginal reflex distance(MRD)-1
RE- 2.5 mm
LE- 5.5 mm
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10.  Marginal reflex distance(MRD)-2
RE- 5 mm
LE- 5.5 mm
 Margin crease distance (MCD)-
RE- 8 mm
LE- 8.5 mm
 Levator function-
RE- 11 mm
LE- 14 mm
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11.  Margin limbal distance-
RE- 8 mm
LE- 10 mm
 Bell’s phenomenon-
RE- present
LE- present
 Corneal sensitivity-
RE- present
LE- present
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12.  Fatigue test-
RE- positive
LE- positive
 Tensilion test-
RE- absent
LE- absent
 Marcus Gunn jaw winking phenomenon-
RE- absent
LE- absent
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13.  Frontalis overaction
RE- Absent
LE- Absent
 Cogan lid twitch test-
RE- Negative
LE- Negative
 10% phenylephrine test:
RE- improves by 2mm
LE- same as before
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14.  Slit lamp examination
ptosis
normal
Conjunctiva-
normal
Cornea-
normal
Pupils- RTL
Lens- normal Lens- normal
RE LE
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15.  Fundus examination
Retina- ON
FR+
Cdr-
normal
RE LE
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16.  Diagnosis-
mild ptosis
 Advice-
ptosis crutch
follow up after 6 months
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17. Ptosis
 Abnormal drooping of upper eyelid
 Classification of ptosis
 Congenital ptosis
 Acquired ptosis
a. Myogenic ptosis- caused by
myopathy of levator function or impaired
transmission of impulses at neuromuscular
junction
 Seen in case of myasthenia gravis, myotonic
dystrophy and LPS muscle trauma
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18. b. Neurogenic ptosis- caused by
innervational defect such as third nerve palsy or
Horner’s syndrome
c. Aponeurotic ptosis- caused by defect
in levator aponeurosis such as senile or postoperative
cases
d. Mechanical ptosis- caused due to
excessive weight on upper eyelid like as in eyelid
tumours, scars and chalazion
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19. Clinical manifestation
 Symptoms
 Asymptomatic if pupil is not covered
 Visual disturbance if pupil is covered
 Cosmetic disfigurement
 Diplopia
 Abnormal head posture and head tilt
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20.  Signs
 Narrow palpebral fissure height
 Absence of upper eyelid crease in case of
congenital ptosis
 Frontalis overaction
 Backward head tilt
 Signs related to underlying cause
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21. Clinical evaluation of ptosis
 History taking-
 Age of onset
 Aggravating or alleviating factors
 Variation in amount of ptosis during the
day
 Associated with diplopia, abnormal head
posture
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22.  Palpebral fissure height-
 Margin reflex distance(MRD)-1
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23.  Margin reflex distance(MRD)-2
 Distance between lower lid margin and pupillary
reflex
 Margin crease distance-
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24.  Levator function-
 Margin limbal distance-
 Distance from middle of upper eyelid to inferior
limbus
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25.  Bell’s phenomenon-
 Corneal sensitivity-
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26.  Frontalis overaction
 Marcus-Gunn jaw winking phenomenon
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27. Normal values
Tests done for ptosis
evaluation
Normal values
Palpebral fissure height 7-10mm(male)
8-12mm(female)
Margin reflex
distance(MRD)1
4-5mm
Margin reflex
distance(MRD)2
>5mm
Lid crease height 5-7mm(male)
8-10mm(female)
Levator function 13-17mm
Margin limbal distance 9mm
Bell’s phenomenon Upward rotation of eyeball
with closure of eyelid
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28.  Tensilion test-
1 mg of neostigmine is injected in a
patient.
In case of Myasthania gravis, ptosis
improves in 5-10 minutes
 Cogan lid twitch test-
Patient is asked to look downwards and
then in primary position quickly. The upper eyelid
retracts and then droops slowly to ptotic condition.
Positive result suggests of Myasthania
gravis in patient.
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29. Pseudoptosis
Right pseudoptosis due to
artificial eye
Brow ptosis
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30. Dermatochalasis
Left pseudoptosis due to
contralateral eyelid
retraction
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31. Management
 Ptosis crutches- to hold the upper eyelid
to avoid eyelid to cover the pupil
 Treat the underlying causes
 Surgery –
 Tarso-conjunctivo-Mullerctomy(Fasanella-
servat operation)
 Levator resection
 Frontalis sling operation
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32. Thank you…
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